* * Anonymous Doc

Thursday, February 24, 2011

"Your daughter is an interesting case," said the attending.

"I don't want her to be an interesting case. I want her to be better."

"Yeah, I'm sorry. Best I can do is 'interesting case.'"

And then the mother burst into tears.

And the attending left to deal with her office hours and I had to deal, alone, with this family that's just been told their daughter is dying... but at least her case is interesting.

Not that I can promise that I would have necessarily not said what the attending said. We swoop in on these people's lives. To us, too often they're 'interesting cases' more than they are 'actual people.'

We sent a patient to rehab yesterday, and as he was being wheeled out he asked if I would come visit him. "Oh, we don't really get to that side of the hospital too often." Is that the best I could do? Probably not. I could probably go visit him for a few minutes while he's in rehab. It probably wouldn't kill me. But I probably won't. And I don't think that makes me unique.

I'm trying to understand why I didn't just say I'd go visit him, and actually mean it. He's a nice elderly man, we spent about 45 minutes talking about his life, while I was talking his history. It was a slow afternoon, I had time. So we talked. He's alone. I could visit him. And maybe it's just the culture -- here specifically or maybe at any hospital, I really don't know. But to walk out the door, across the street, over to the rehab side and... and answer questions about why I'm there? If someone from rehab came over to our side to visit a patient, it would probably be totally fine. No one would necessarily assume he was trying to interfere or take over the case. It would be fine.

Part of it is time, sure. It's probably 20 minutes to get over there, visit a patient, and then come back-- there aren't 20 minutes to do that-- except there would be, if I wanted there to be, I guess-- although we never leave the building during a shift, and I don't think I'd feel comfortable going over there during a shift, so I'd be adding 20 minutes onto my day at one end or the other, and-- why am I trying to rationalize this? The patients feel closer to us than we feel to them, that's just what it is, right? I can't get attached, because most them die. Even if not now, then soon. The 'interesting case' is probably going to die. It is sadder for her to be a person than for her to be an 'interesting case.'

"I leave it to you," the attending said in his note about the interesting case. "Do whatever you think we should do." I panicked. This isn't guidance. I've almost gotten to the point where I know how to manage uninteresting cases on my own. Boring, standard cases that we see over and over again, I can handle. But interesting cases, I need help. I asked for help. I asked every specialist we saw for help on this one. "Keep doing what you're doing," "I'd get a chest x-ray," "seems like you should check the electrolytes," etc. She's stable, and slightly less interesting. So I've probably done my job. I don't know. What is my job if there is no medical solution? Is it to pretend we're helping? Is it to comfort them? Is it to visit my patient in rehab?


  1. This is appalling. Why can't doctors just be themselves? If you are the type of *person* who would visit someone under those circumstances, then go and visit him over in rehab. If you aren't the kind of person who does that, then don't do it, forget about it and don't dwell on it. But, I suspect that you might be the kind of person who would be inclined to visit, which is why you are battling yourself about it.

  2. If the rehab patient has been your patient long-term, then visiting would be appropriate but not necessary if you are inclined to make time. Less so if this is someone you just met.

    No medical solution? Don't say it's an interesting case and walk away so they feel devastated by the situation and abandoned by those they thought would help. There are ways to help even if you can't cure. Be honest and compassionate. Take an extra couple minutes to explain things. Expect that they'll forget at least part of it and need it gone over again. Hand the family a pad of paper and pencil with the suggestion that they write down their questions - which makes it look like you're willing to later answer those questions. It looks like you're available and will be there for them. That helps.

  3. In photography they have a saying: "f/8 and be there." Translation: f/8 is the default lens setting (akin to the point and shoot type of camera). What this really means is that you have to be there in order to take the picture. And in internal medicine, more times than I would like to admit, Being There is all we can really do. Even if we don't want to do it.

    I have two bedbound patients I really ought to see, but it would involve my making a couple of house calls. I have spent a fair amount of today arguing with myself about taking part of my weekend to go and see them - I just didn't want to. But now I'm going to. I hope you'll drop by and see the fellow who's going to rehab. Trust me, it would do him a lot of good if you make the effort to just drop by.

  4. Wow - as a patient who is an interesting case herself, the attending here is appalling.

    I'm not dying soon right now, mostly because after going through a bunch of Doctors who outright refused to treat me or treated me with the wrong medications, I finally found someone who's willing to research and experiment.

    Multiple 'co-morbid' chronic conditions make me a tough patient; I get that. But telling me not to bother to come back unless I need a flu shot or have a garden variety uncomplicated cold is wrong. And even worse is taking me off all the medications that had things at least under control because "they're not natural" (and no, this wasn't a homeopath etc, but a highly recommended endo/gp) to try something natural, which made my hair fall out on top of everything else.

    I know not all doctors are like this, but I've run into a bunch of them back-to-back. I'm terrified to go to the hospital for anything because patients with chronic diseases seem to be treated like incompetent, drug-seeking idiots, and the wrong treatment could throw things off for months.

    My point being, your attending was wrong, and the others who kept you digging to help at least short term weren't. If your patient is anything like me (or the other "interesting cases" I know) being a walking lab rat is frustrating but we'll cope if there's some chance of improvement. Hell, every time we start a new batch of medications they get added one at a time, with any changes being tracked a few times a day - how else can I keep things straight to report back on the experiment?

    Good luck with her, and even if it's just to make things less painful, you're doing the right thing.

  5. You are just overworked and stressed to deal with your emotions, your patient's emotions and your Attending should've been the good role model but wasn't. I'm sure if she set the tone, you'd follow because you would be impressed by her compassion. Instead, at the end of the day- everyone is watching the clock cause everyone just wants to go home and rest, like the lab people who gets to clock out at 5.

    Just remind yourself why you got into medicine and then you'd start making the right decisions. It's easy to forget when you have 27 inpatients to round on.

  6. If a physician told me I were an "interesting case", I'd find myself another physician, immediately, or, depending upon the situation, explore immediate palliative care and/or hospice. Then I'd discontinue that physician's involvement entirely. It's obvious what his priorities are, and I'd deny him the satisfaction of following my "interesting" case. I'd tell him why, too: I've seen too many friends and family members die badly.

    Be different, is my advice to you.